Medical Record Release




HIPAA RELEASE AND AUTHORIZATION

Recipient. My medical records shall be disclosed to the following individual or entity:

Name: Optimal You, LLC 

Contact: Mia Hartman, FNP-C 

Address: 5558 US RT 5, Newport, VT 05855 

Phone: 802 323 2632 

Email: Nphartman.22@gmail.com 

Fax: 802 219 8688 

Purpose of Release: Continuation of Care 

Expiration: This authorization expires on: 01/01/2030

I understand that signing this authorization is voluntary and that my treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon whether I sign this authorization. 
I understand that I have the right to revoke this authorization at any time by writing to the Releasor, except where uses or disclosures have already been made based upon my original permission. 
 I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA.

I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.

By checking this box, I agree to use electronic records and signatures and I acknowledge that I have read the related consumer disclosure.
 I am the parent/guardian of this patient
I [type name below] authorize the release of the release of my complete health record*
I authorize [type name of facility releasing your health information] to use or disclose the following*
- ALL Medical Records. I request the release of my complete health record, which may or may not include protected health information (PHI) and electronic protected health information (ePHI) protected under HIPAA. Restrictions - Medical information relating to diagnosis and treatment of alcohol or drug abuse, mental illness, STDs, or HIV/AIDS shall: (chose one)*
Specific Medical Records: [DESCRIBE MEDICAL RECORDS (IF APPLICABLE)]